Historical Medical Policies and Clinical UM Guidelines
Historical Medical Policies
Medical policies contained within this page are historical and not the most current versions. Current medical policy content may be accessed from the Medical Policies and Clinical Utilization Management (UM) Guidelines page.
Implementation dates of the most current versions vary per state notification requirements.
- LAB.00045 Selected Tests for the Evaluation and Management of Infertility
- MED.00145 Digital Therapy Devices for Treatment of Amblyopia
- OR-PR.00008 Osseointegrated Limb Prostheses
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
- SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
- SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
Historical Clinical UM Guidelines
Clinical UM guidelines contained within this page are historical and not the most current versions. Current clinical UM guideline content may be accessed from the Medical Policies and Clinical Utilization Management (UM) Guidelines page.
Implementation dates of the most current versions vary per state notification requirements.
- CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous
- CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
- CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-SURG-119 Treatment of Varicose Veins (Lower Extremities)
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